Fill your Vraylar prescription We will look up your insurance coverage and submit where possible. "*" indicates required fields Vraylar (cariprazine)Our team will use your information provided below to look up your insurance benefits. * 1.5mg for $15/90 days 3.0mg for $15/90 days 4.5mg for $15/90 days 6.0mg for $15/90 days Name* First Last D.O.B.* MM slash DD slash YYYY Gender* Email* Phone Number*This is the number where you will receive text messages regarding your prescription and shipping confirmation.Shipping Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Would you like us to set your presciption up for auto refill so that we can fill the medication(s) for your every month / 3 months, and get it ready for you so you don't have to worry about running your of medication?* Yes No Allergies to any medications?* Yes No Please list your medication allergies.(If yes please list here)Are you taking any other medications?* Yes No Are you taking any other medications?(If yes please list here)Card Number* Expiration Date* Card CVV* If you would like a pharmacist to call you regarding questions about your prescription(s) or to go over counseling points for any specific medication(s), please check here and a pharmacist will reach out to you directly. Always feel free to call us anytime.* Yes No
